Deputy Health and Disability Commissioner Rose Wall today released a report finding the owner of a rest home in breach
of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide appropriate care to
one of its residents when her condition deteriorated.
The woman, in her seventies, had numerous health conditions and had suffered a stroke. While at the rest home, she
became delirious, dehydrated and feverish, and developed a sore on her leg. Staff failed to regularly monitor her
condition over subsequent days and she was eventually transferred to hospital, where she died due to blood poisoning
Ms Wall considered that there was a pattern of failings involving multiple staff. Nursing staff failed to follow up on
concerns and carry out necessary assessments and observations. Concerns about the woman’s condition were not documented
or handed over adequately, and the woman’s pressure injury was not treated with the urgency it required. In addition,
the woman’s care plans were not kept up-to-date.
"[This case] highlights the importance of care coordination amongst staff, updating resident care plans, undertaking
appropriate assessments as required, and documentation of care, concerns, and clinical reasoning," Ms Wall said.
"The care plans were not used as a living document to drive patient-centric care across shifts, and further the lack of
observation charts meant that the ability of nursing staff to deliver continuity of care, in consideration of [the
woman’s] changing needs across shifts, was constrained."
Ms Wall made a number of recommendations for the rest home’s service improvement, including that it develop policies to
better support nursing staff in their clinical decision-making. She also recommended that the rest home provide regular
education sessions for staff regarding monitoring sick patients, short-term care plans and documentation. It was
recommended that the rest home conduct audits of 20 current residents to ensure that appropriate wound management is
being carried out and that care plans and assessments are up-to-date. Ms Wall asked the rest home to apologise to the
The full report for case 18HDC00678 is available on the HDC website